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The effectiveness and sustainability of peer support interventions for persons living with HIV: a realist synthesis
  1. Shuyu Han1,
  2. Yizhu Zhang1,
  3. Xianxia Yang2,
  4. Xinru Chai1,
  5. Jinzheng Guo1,
  6. Lili Zhang3,
  7. Ying Shao4,
  8. Jianhong Ma4,
  9. Ke Li5,
  10. Zhiwen Wang1
  1. 1School of Nursing, Peking University, Beijing, People's Republic of China
  2. 2School of Public Health, Wuhan University, Wuhan, Hubei, People's Republic of China
  3. 3Department of Nursing, Beijing Youan Hospital Affiliated with Capital Medical University, Beijing, People's Republic of China
  4. 4Department of Infection, Beijing Youan Hospital Affiliated with Capital Medical University, Beijing, People's Republic of China
  5. 5Department of Emergency, Peking University First Hospital, Beijing, People's Republic of China
  1. Correspondence to Professor Zhiwen Wang; wzwjing{at}sina.com

Abstract

Background Peer support is an important supplement to medical resources for persons living with HIV (PLHIV). However, previous studies have shown mixed results about intervention effects. It is necessary to explain the mechanism of peer support interventions’ effectiveness and sustainability to help design more valid peer support interventions.

Objective To identify and explain the mechanisms that drive the effectiveness and maintain the sustainability of peer support interventions.

Methods A preliminary theoretical framework was developed through a scoping review of the grey literature and international project frameworks in five professional websites. We then refined the framework by systematically searching evidence in databases including PubMed, EMBASE, Web of Science, ProQuest, CINAHL, CNKI and Wanfang. Qualitative methods were used to generate codes and themes relating to the studies’ context, mechanisms and outcomes. We checked chains of inference (connections) across extracted data and themes through an iterative process.

Results A total of 6345 articles were identified, and 52 articles were retained for final synthesis. The refined theoretical framework presents five areas of peer support, including informational support, instrumental support, emotional support, affiliational support and appraisal support; five types of outcomes that peer support can improve for PLHIV, including physiological outcomes, psychological outcomes, behavioural outcomes, cognitive outcomes and social outcomes; the effectiveness mechanism coding system from peer volunteers and the relationship between peer volunteers and PLHIV; and the sustainability mechanism coding system in terms of peer volunteers, PLHIV and study context.

Conclusions Given that peer support has huge potential human resources, that is, all the qualified PLHIV, irreplaceable advantages in dealing with barriers to HIV-related discrimination and potential comprehensive benefits for PLHIV, it is necessary to develop and organise more peer support projects for PLHIV. Our study highlights that the expansion of peer support projects should be based on their effectiveness and sustainability.

PROSPERO registration number CRD42022339079.

  • HIV
  • AIDS
  • systematic review

Data availability statement

No data are available.

http://creativecommons.org/licenses/by-nc/4.0/

This is an open access article distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited, appropriate credit is given, any changes made indicated, and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/.

https://doi.org/10.1136/bmjgh-2022-010966

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    WHAT IS ALREADY KNOWN ON THIS TOPIC

    • Peer support is an important supplement to medical resources and a common strategy for preventing HIV and promoting health worldwide. However, the intervention effects of peer support are greatly influenced by the study context and have shown mixed results in previous studies. Many HIV peer support studies have only shown short-term intervention effects.

    WHAT THIS STUDY ADDS

    • This realist synthesis provides a theoretical framework that explains the mechanisms driving the effectiveness and sustainability of peer support interventions. The effectiveness mechanisms include coding system from peer volunteers and the relationship between peer volunteers and persons living with HIV (PLHIV). The sustainability mechanisms include a coding system in terms of peer volunteers, PLHIV and study context.

    HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY

    • This framework helps contribute to designing effective and sustainable peer support interventions for PLHIV, thus improving PLHIV’s health outcomes and saving medical resources.

    Introduction

    With the advent of antiretroviral therapy (ART), HIV infection has become a chronic disease.1 The goals of HIV treatment and care are no longer just about prolonging the lives of people living with HIV (PLHIV), but more about improving their quality of life.2 Medical resources need to cover all the PLHIV with a diagnosis of HIV infection regardless of any stages. This transition poses additional challenges to the healthcare system to meet PLHIV’s various medical care needs, especially in environments where medical resources are in short supply.3 Previous studies indicate that PLHIV commonly confronts various distress and unmet medical care needs.4 5 Moreover, the issue of HIV-related discrimination also acts as a barrier to PLHIV seeking medical and psychosocial support.6 7 Therefore, more medical care resources, especially those that can lower PLHIV’s psychological defences, are needed to improve PLHIV’s quality of life, thus promoting the achievement of the ‘95-95-95’ goal (95% of PLHIV know their HIV infection, 95% of PLHIV with HIV-positive diagnosis receive ART, 95% of PLHIV on ART achieve viral load suppression)8 and improving health-related quality of life for PLHIV at any stage.9

    Peer support is defined as ‘the giving of assistance and encouragement by an individual considered equal’.10 It is an important supplement to medical resources and a common strategy for preventing HIV and promoting health worldwide.11 Common peer support forms in the field of HIV care include but are not limited to peer education and peer counselling by other PLHIV.12–14 Compared with medical professionals, peer volunteers can generate more interpersonal interactions with PLHIV and offer them more authentic empathy and validation because of their similar experiences, which have irreplaceable advantages in the context of HIV-related discrimination.15 They can even offer practical advice and suggestions that professionals may not offer or even know about.16 By drawing on their own lived experience, peer volunteers can offer practical advice on the day-to-day aspects of living with HIV, advice that extends beyond the expertise of clinically-based medical professionals. Furthermore, peer support is more cost-effective and provides potentially more access than traditional services from medical care providers.17 18 Therefore, many countries, such as the UK,19 Australia20 and Canada,21 have published national standards or practice guidelines for peer support for HIV. The United Nations Programme on HIV/AIDS (UNAIDS) also proposed the Greater Involvement of People Living with HIV (GIPA) principle to advocate for more participation and contribution of peer volunteers.22

    Previous studies have validated the effects of peer support on many outcomes, such as helping PLHIV improve mental health, social support, medication adherence, HIV care visit adherence and viral suppression.23–26 The intervention effects of peer support have also been verified among different specific characteristics, such as adolescents living with HIV,27 28 mothers living with HIV29 30 and PLHIV in prison or jail.31 However, the intervention effects of peer support are greatly influenced by the study context.32 Moreover, many HIV peer support studies have only shown short-term intervention effects.32 33 PLHIV may not continue to benefit after the completion of the peer support project. Consequently, it is necessary to explain significant components and factors of peer support interventions’ effectiveness and sustainability, that is, the mechanisms, to help design more valid peer support interventions. This study aims to conduct a realist synthesis to propose a theoretical framework with context-mechanism-outcome (CMO) configurations34 to explain the effectiveness and sustainability of HIV peer support interventions. Our attempt provides important insights to help activate and realise potential great contributions to promoting PLHIV’s health.

    Methods

    This realist synthesis is reported according to the Realist and Meta-narrative Evidence Syntheses: Evolving Standards quality and publication standards (RAMESES).35 We prospectively registered the current review in the PROSPERO database.36 The realist synthesis method with five steps was applied for this review.37

    Step 1: formulating a preliminary theoretical framework

    The preliminary theoretical framework was developed through a scoping review of the grey literature and international project frameworks from five websites, including Canada’s Source for HIV and Hepatitis C Information (CATIE),38 British HIV Association (BHIVA),39 National Association of People with HIV Australia (NAPWHA),40 National HIV Nurse Association (NHIVNA)41 and UNAIDS.42 Considering that these websites lack advanced search functions, we only applied basic and sample search strategies. Free terms including ‘HIV’ and ‘peer’ were used to perform the search in May 2022. One researcher (SH) screened all the records, included records according to the relevance of the study objectives and extracted supportive information for the preliminary theoretical framework in terms of, areas of peer support interventions, types of outcomes, effectiveness mechanisms and sustainability mechanisms. A record was included if it was relevant to at least one aspect of the extracted information.

    Step 2: search strategy

    Our search strategy can be divided into three stages. First, we conducted a preliminary search in PubMed to develop search strategies tailored to each database. The expanded search strategies were discussed with the research team before conducting systematic searches in each database. Second, we implemented the search strategies in PubMed, EMBASE, Web of Science, ProQuest, CINAHL, CNKI and Wanfang. Both free terms and Medical Subject Headings were used in each database if applicable. We limited the publication date to after 1 January 1996 because ART was broadly introduced after 1996.1 The detailed search strategies for each database are available in online supplemental appendix I. Third, the references of all the included articles were reviewed to identify eligible literature not found in the systematic search strategies. During the framework refinement process, the necessary purposive iterative searching was conducted to identify additional articles that might support any element in the framework. The search stopped when there was sufficient evidence to reasonably claim that the final theoretical framework was plausible.

    Supplemental material

    Step 3: study selection criteria

    All the records searched from the database were imported, and duplicates were removed in NoteExpress. Two researchers (SH and KL) who had been trained in evidence-based methodologies independently filtered the records by reading titles and abstracts to initially exclude literature that was not relevant to the theoretical framework. A third researcher (ZW) resolved disagreements in the preliminary study selection process.

    The inclusion criteria were as follows: (1) Population: PLHIV aged 18 years and older in any country or setting regardless of any stage of HIV. We excluded PLHIV who were in special situations, including pregnancy, in prison and with severe mental health diseases. (2) Intervention: Any intervention provided by HIV-positive peer volunteers was eligible for this review. We did not limit the types of peer support interventions available. However, to clarify the intervention effectiveness of peer support, we only included clinical trials in which peer volunteers were the unique intervention providers. Clinical trials with multiple types of intervention providers (such as medical professionals and psychologists) that did not report clear intervention doses were excluded. (3) Language: We only included articles that were published in English or Chinese. There were no exclusions based on the outcomes of HIV peer support projects, study design or study quality of the involved articles. Study designs other than clinical trials were not restricted as seriously as clinical trials in terms of intervention. For instance, the background of a qualitative study might be an HIV peer support project delivered by both peer volunteers and medical professionals. However, the results of the qualitative study were only focused on peer support. Under these circumstances, this qualitative study was eligible for the current study. Every excluded study was recorded along with the reason for its exclusion.

    The full-text screening was completed by the whole research team with members working in pairs and the papers divided among the team. Each article that was involved in the preliminary screening process was assessed for its relevance to the content in framework refinement. Generally, it is likely that only a fragment rather than the entire study will inform the theoretical framework in a realist synthesis. Therefore, consistent with the development process of the preliminary theoretical framework, a record was included if it was relevant to at least one element in the framework according to the CMO configurations. Any exclusion in this process was recorded and reasons why were noted.

    Step 4: data extraction

    A standardised Excel spreadsheet was used to record the extracted characteristics of the original studies involved. The characteristics of the involved original studies include author (year), setting, objectives, study design, participants, interview method, intervention and results. The data extraction process was performed by two researchers (SH and KL) independently and checked by a third researcher (ZW).

    Step 5: data analysis and synthesis

    Five steps for data analysis and synthesis were followed.43 First, the extracted data and their references were summarised and organised into draft evidence tables. Second, qualitative methods were used to generate codes and themes relating to the CMOs. Third, we checked chains of inference (connections) across extracted data and themes through an iterative process. Fourth, new COM configurations arose according to the chains of inference. Fifth, the preliminary theoretical framework was refined by all the supportive evidence. This process was conducted by one researcher (SH), reviewed by another researcher (KL) and discussed with the research team.

    Results

    Preliminary theoretical framework

    A total of 1111 records were identified from the five professional websites. After reviewing and screening these records, we finally included 21 records, including six videos, to develop the preliminary theoretical framework. The links to these 21 records are available in online supplemental appendix II.

    Supplemental material

    As shown in figure 1, we initially identified four types of peer support interventions44 45: (1) informational support: peer volunteers provide knowledge and personal experience with PLHIV; (2) emotional support: peer volunteers help PLHIV vent their emotions, express love and care and convey positive beliefs; (3) appraisal support: peer volunteers encourage PLHIV decision-making by providing information, and weighing the pros and cons; and (4) instrumental support: peer volunteers provide material or monetary support to PLHIV. To develop effective and sustainable peer support, researchers need to pay attention to the following key points20 21 45–47: choosing qualified peer volunteers, providing effective training with peer volunteers, ensuring ongoing supervision and feedback, mitigating peer volunteers’ compassion fatigue and burnout, providing easy access to peer support with PLHIV, matching peer volunteers with PLHIV and providing PLHIV with tailored services and attaching peer support projects with open platforms.

    Figure 1
    Figure 1

    The preliminary theoretical framework.

    When PLHIV receive effective peer support interventions, they may feel a sense of compatibility, empathy, acceptance and benefit.20 These are the mechanisms by which peer support improves PLHIV’s outcomes. By reviewing peer support interventions in the scoping review, we summarised that peer support interventions could improve PLHIV’s five types of outcomes20 21: (1) physiological outcomes, such as an increase in CD4 cell counts and decrease in viral load; (2) psychological outcomes, such as relieving depression and anxiety; (3) cognitive outcomes, such as increasing confidence and supporting feelings of being in control of their own health; (4) behavioural outcomes, such as improving medication adherence and retention in care; and (5) social outcomes, such as creating social connections and enabling PLHIV to go back to work.

    Literature search

    As shown in figure 2, a total of 6345 articles were identified after searching seven databases. We removed 1109 records through NoteExpress and retained 5236 articles for screening. During the preliminary screening stage, we excluded 4604 records by reviewing the titles and abstracts. We finally included 52 articles after reviewing 632 full texts and conducting snowballing. Of the 52 included articles, the relevance of 46 articles was agreed between two researchers and included directly. The inter-rater reliability was 0.885. Other six included articles were discussed in the research group before their inclusion.

    Figure 2
    Figure 2

    Flowchart of the identification and selection of studies.

    Study description

    Table 1 presents the research details of each included article. Of the 52 included studies, 49 were published in English and 3 were published in Chinese. The year of publication ranged from 2005 to 2022. Study settings involved 17 countries, including 19 studies in the USA, 6 studies in South Africa, 5 studies each in China and Uganda, 3 studies in Canada, 3 studies each in Vietnam and Mozambique and 1 study each in Spain, Norway, Australia, Zimbabwe, South Korea, India, Dominican Republic, UK, Myanmar and Nigeria. Of these studies, 21 were clinical trials, 20 were qualitative studies, 7 were mixed-method studies, 3 were cross-sectional studies and 1 was a cohort study.

    View this table:
    Table 1

    Study characteristics

    The refined theoretical framework

    What can peer volunteers provide for PLHIV?

    As shown in figure 3, the refined theoretical framework identifies peer support into five areas in terms of intervention contents: informational support, instrumental support, emotional support, affiliational support and appraisal support.48–51Informational support requires peer volunteers to educate PLHIV about a variety of topics and help them better comprehend medical information from their healthcare providers.49 52 Instrumental support can be divided into medical instrumental support, such as referring and transporting PLHIV to medical professionals, scheduling appointments and making calls to remind PLHIV of appointments48 51; and daily life instrumental support, such as substance abuse treatment support and food and housing security support.48 Emotional support is an important component of peer support. PLHIV also show huge unmet needs for emotional support.51 To provide emotional support to PLHIV, peer volunteers sometimes may not need to have complex professional psychological skills. It truly does work if peer volunteers just listen to PLHIV to help them alleviate their negative emotions. Other emotional support may include using listening and reflective techniques to help PLHIV gain confidence in their ability to change health-related behaviours48; appealing to PLHIV’s emotions to reinforce or change behaviours53; and demonstrating caring, empathy and comfort to help PLHIV begin to engage in HIV care and treatment.54 Affiliational support aims to help PLHIV reduce isolation and connect to social networks.48 55 Appraisal support aims to help PLHIV make decisions about their treatment, self-care and daily life conflicts by providing information, weighing the pros and cons and conducting motivational interviews.50

    Figure 3
    Figure 3

    The refined theoretical framework. PLHIV, persons living with HIV.

    What outcomes can peer support improve?

    We summarised the following types of outcomes that peer support can improve according to the involved clinical trials: physiological outcomes (viral load suppression56–58 and pain59), psychological outcomes (quality of life60), behavioural outcomes (risky behaviours,12 14 medical care compliance56 57 61 62 and medication adherence56 63–65) and cognitive outcomes (HIV knowledge,66 67 self-awareness of behaviour problems68 and enacted and internalised stigma56 66). Although there was limited evidence of effectiveness on psychological outcomes and social outcomes among clinical trials, in qualitative studies, PLHIV reflected that they acquired these benefits. PLHIV reported that peer support can help them reduce loneliness and increase their sense of attachment, sense of belonging, sense of worth, disease acceptance, confidence and hope.51 53–55 69 Social activity engagement was also improved after attending the peer support project.67

    What is the mechanism that improves the effectiveness of peer support?

    Peer volunteers

    Ensuring peer volunteers are appropriately qualified is an important aspect of effective peer support programmes. Qualified peer volunteers should: first, receive adequate training70 71; second, provide tailored service to meet PLHIV’s personal needs50 72–75; third, provide continuous support beyond the clinical setting52; fourth, act as a bridge between PLHIV and their social relationships, community and the health system52 76–78; and fifth, convey and translate critical information.52

    Peer-PLHIV relationship

    A positive communication and atmosphere between peer volunteers and PLHIV is essential to guarantee intervention effects.67 69 First, the reciprocal support makes peer volunteers and PLHIV satisfied by receiving and providing support.79 Second, PLHIV take peer volunteers as role models and are encouraged by peer volunteers’ experiences and positive attitudes.76 80 Third, PLHIV feel acceptance and empathy through free expression in a positive atmosphere.54 69

    What is the mechanism that maintains the sustainability of peer support?

    Peer volunteers

    To improve the sustainability of peer support interventions, it is important to reduce the attrition of peer volunteers.70 74 81 On the one hand, peer support projects should improve the positive experience of peer volunteers, including their sense of achievement74 81 and sense of belonging.81 82 The sense of achievement comes from helping others76 and personal growth.54 74 79 Some peer volunteers reported that participating in peer support can help improve self-management skills, regulate their own mental health and is an important way to give back to society.74 On the other hand, it is necessary to quickly identify and reduce peer volunteers’ negative feelings during practice, including emotional burnout74 81–83 and worriers about privacy exposure.74 81 84 Emotional burnout may come from negative feedback from PLHIV, repetitive work and work-related stress.69 74 81 82 85

    PLHIV

    In terms of PLHIV, researchers should design effective measures to maintain PLHIV’s confidentiality,52 55 86 and make them have perceived benefits.55 Perceived benefits can include perceived improvement or belief in improving one or more outcomes of physiological outcomes, psychological outcomes, behavioural outcomes, cognitive outcomes and social outcomes.

    Study context

    The following components in the study context are related to the sustainability of the intervention project. First, the peer support project needs sufficient financial support to pay peer volunteers’ salary and guarantee project operation.56 76 81 82 Second, access to a safe place reassures both PLHIV and peer volunteers of privacy exposure concerns.53 Third, more communication between peer volunteers and medical staff is necessary to reduce the information gap and to better integrate volunteers into the clinical setting.52 55 70 83 Fourth, the context should provide continuous training for peer volunteers to meet their self-growth needs and be more effective in their role as peer supporters.82

    Discussion

    To our knowledge, this is the first realist synthesis about peer support for PLHIV. The theoretical framework summarises the type of interventions that peer volunteers can provide and the potential type of outcomes that peer support can help PLHIV improve. Specifically, this theoretical framework comprehensively explains the mechanisms for developing effective and sustainable peer support interventions. Our attempt may provide researchers with theoretical reference for peer support project design and practice and motivate peer volunteers in the health management of PLHIV.

    Evidence indicates that peer volunteers can provide various areas of support, including informational support, instrumental support, emotional support, affiliational support and appraisal support. Interventions in included clinical trials also usually included at least one type of support. Therefore, peer volunteers are important resources for providing comprehensive support for PLHIV beyond medical professionals. Many qualitative studies have shown the great necessity of emotional support.51 53–55 69 However, we found only weak evidence that peer support has intervention effects on psychological outcomes. We estimate that it may be associated with the following factors. First, most of the clinical trials took emotional support as a secondary intervention component, and the intervention dose may not be enough to show an intervention effect.12 14 59–61 87–89 Second, measurement tools may not be sensitive to test the intervention effect.14 61 88 Third, small sample sizes may not have enough power to test the intervention effect.59 63 87 We suggest that researchers pay more attention to peer volunteers’ emotional support skill training and encourage more peer-led emotional support for PLHIV. They should not just evaluate the necessity of peer volunteers’ emotional support through evidence of quantitative data.

    We also summarised that peer support could help PLHIV improve various outcomes, including physiological, psychological, behavioural, cognitive and social outcomes. This evidence indicates the huge value of peer support for PLHIV’s health management, and the necessity of the GIPA principle for promoting the ‘95-95-95’ goal and improving health-related quality of life for PLHIV.8 9 22 Of these outcomes, behavioural outcomes, such as medical follow-up adherence, risky behaviour and medication adherence, were more frequently tested in clinical trials.12 14 57 58 61–65 68 89–92 Future studies could attempt to evaluate other types of outcome effects. Moreover, we could not clarify the specific mechanism of the peer support intervention effect on each kind of outcome. Our framework only presents the general chain of intervention (context) - mechanism - outcome. Future studies could focus on explaining the specific CMO chain, such as the mediating role between specific types of peer support interventions and specific outcomes.

    The refined theoretical framework shows comprehensive mechanisms that explain the effectiveness and sustainability of peer support projects. Designing effective interventions should focus on the qualification of peer volunteers and the relationship between peer volunteers and PLHIV during the intervention operation. To ensure that peer volunteers are appropriately qualified, it is crucial to design adequate training. The type of peer support intervention can provide a framework reference for designing the training programme. Peer volunteers who receive adequate training can provide tailored service and continuous support beyond medical care service for PLHIV and play a bridging role in their social relationships. This is also a good continuation of and supplement to medical services. Peer volunteers effectively convey and translate critical information throughout the service, laying the foundation for establishing a positive connection and atmosphere with PLHIV. If PLHIV consider peer volunteers as their role models because of their positive attitudes and experiences, they may benefit from the peer-PLHIV relationship more easily. PLHIV feel accepted and empathetic in a positive relationship and atmosphere. They not only have the role of being helped but also benefit from helping others, that is, establishing reciprocal support with peer volunteers.

    To improve the sustainability of peer support projects, researchers should consider factors in terms of peer volunteers, PLHIV and context. A sufficient reserve of peer volunteers is an important foundation for maintaining projects’ sustainability. Therefore, researchers should take effective measures to reduce the attrition of peer volunteers. Evidence indicates that peer volunteers report mixed feelings during the process of supporting PLHIV.54 69 74 76 79 81–85 Their positive feelings need to be reinforced, and their negative feelings need to be adjusted in time. Emotional support is also necessary for peer volunteers in projects.74 85 Project administrators can arrange psychologists or peer volunteers to provide support for them. If PLHIV feel little risk of privacy exposure and may acquire anticipated benefits, it will contribute greatly to the sustainability of the peer support programme.51 55 PLHIV’s positive attitudes toward and impressions of peer support projects are closely associated with the success of previous projects, that is, the mechanism 1 may affect the mechanism 2. For the context, researchers should provide a safe environment where both peer volunteers and PLHIV feel little risk of privacy exposure. Policymakers or hospital managers should also fully evaluate the cost-effectiveness of peer support projects, provide continuous and stable financial support for peer volunteers as compensation for their time, consider integrating peer support projects into medical care routines and raise peer volunteers as essential members of the medical team.55 81

    Peer support is an important continuation of and supplement to medical services. It not only helps save medical resources and reduce medical healthcare workers’ workload, but also can provide crucial support for PLHIV that is beyond the expertise of medical professionals. To maximise the role of peer support, peer volunteers should not be independent and separated in the medical context. More awareness and communication between peer volunteers and medical professionals are necessary to help peer volunteers better integrate into the medical context.52 83 The process of communication also provides good opportunities for project feedback and communication. The medical context also needs to provide continuous training for peer volunteers, which meets PLHIV’s need for knowledge updates and self-management; it also helps peer volunteers better service PLHIV and promote the sustainability of peer support projects.81

    Several limitations of this study should be noted. First, we only included articles published in English and Chinese, which may affect the results of this study due to language restrictions. Second, we only conducted qualitative data analysis and synthesis. Therefore, we cannot identify and compare effect sizes between different types of interventions and cannot define which components of the interventions are more effective. Third, although the theoretical framework summarised and synthesised from this review provides a comprehensive mechanism of peer support projects’ effectiveness and sustainability, we did not assess the risk of bias of the included original studies.

    Conclusion

    This realist synthesis summarises and presents a theoretical framework that explains the mechanisms of peer support interventions’ effectiveness and sustainability. Evidence indicates that the effectiveness mechanisms include coding system from peer volunteers and the relationship between peer volunteers and PLHIV. Mechanisms for sustainability include a coding system in terms of peer volunteers, PLHIV and study context. We suggest that researchers and practitioners comprehensively consider these mechanisms when designing and conducting peer support projects. It may help activate and realise more contributions of peer support for promoting PLHIV’s health.

    Data availability statement

    No data are available.

    Ethics statements

    Patient consent for publication

    Ethics approval

    Not applicable.

    References

    1. ↵
      1. Antiretroviral Therapy Cohort Collaboration
      . Survival of HIV-positive patients starting antiretroviral therapy between 1996 and 2013: a collaborative analysis of cohort studies. Lancet HIV 2017;4:e349–56. doi:10.1016/S2352-3018(17)30066-8
      OpenUrlPubMed
    2. ↵
      1. Lazarus JV,
      2. Safreed-Harmon K,
      3. Barton SE, et al
      . Beyond viral suppression of HIV - the new quality of life frontier. BMC Med 2016;14:94. doi:10.1186/s12916-016-0640-4
    3. ↵
      1. Safreed-Harmon K,
      2. Anderson J,
      3. Azzopardi-Muscat N, et al
      . Reorienting health systems to care for people with HIV beyond viral suppression. Lancet HIV 2019;6:e869–77. doi:10.1016/S2352-3018(19)30334-0
      OpenUrl
    4. ↵
      1. Dong N,
      2. Chen W-T,
      3. Lu H, et al
      . Unmet needs of symptom management and associated factors among the HIV-positive population in Shanghai, China: a cross-sectional study. Appl Nurs Res 2020;54:151283. doi:10.1016/j.apnr.2020.151283
      OpenUrl
    5. ↵
      1. Zhu Z,
      2. Hu Y,
      3. Guo M, et al
      . Urban and rural differences: unmet needs for symptom management in people living with HIV in China. J Assoc Nurses AIDS Care 2019;30:206–17. doi:10.1097/JNC.0000000000000025
      OpenUrl
    6. ↵
      1. Kalichman SC,
      2. Katner H,
      3. Banas E, et al
      . Cumulative effects of stigma experiences on retention in HIV care among men and women in the rural southeastern United States. AIDS Patient Care STDS 2020;34:484–90. doi:10.1089/apc.2020.0144
      OpenUrl
    7. ↵
      1. Sakyi KS,
      2. Lartey MY,
      3. Kennedy CE, et al
      . Barriers to maternal retention in HIV care in ghana: key differences during pregnancy and the postpartum period. BMC Pregnancy Childbirth 2020;20:398. doi:10.1186/s12884-020-03067-8
    8. ↵
      1. Memiah P,
      2. Tlale J,
      3. Shimabale M, et al
      . Continuous quality improvement (CQI) institutionalization to reach 95:95:95 HIV targets: a multicountry experience from the global south. BMC Health Serv Res 2021;21:711. doi:10.1186/s12913-021-06731-7
    9. ↵
      1. Arora AK,
      2. Lessard D,
      3. Dubé K, et al
      . Brief report: it’s time to embed health-related quality of life across all steps of the HIV care cascade. J Acquir Immune Defic Syndr 2022;91:251–4. doi:10.1097/QAI.0000000000003051
      OpenUrl
    10. ↵
      1. Dennis C-L
      . Peer support within a health care context: a concept analysis. Int J Nurs Stud 2003;40:321–32. doi:10.1016/s0020-7489(02)00092-5
      OpenUrlCrossRefPubMedWeb of Science
    11. ↵
      1. Øgård-Repål A,
      2. Berg RC,
      3. Fossum M
      . A scoping review of the empirical literature on peer support for people living with HIV. J Int Assoc Provid AIDS Care 2021;20:23259582211066401. doi:10.1177/23259582211066401
    12. ↵
      1. Hart TA,
      2. Noor SW,
      3. Skakoon-Sparling S, et al
      . GPS: a randomized controlled trial of sexual health counseling for gay and bisexual men living with HIV. Behav Ther 2021;52:1–14. doi:10.1016/j.beth.2020.04.005
      OpenUrl
    13. ↵
      1. Knudson A,
      2. Shaw S,
      3. Yin L, et al
      . Exploration of implementation patterns and content from a text-based outreach intervention clinical trial for newly diagnosed, HIV-positive MSM in Beijing, China. AIDS Behav 2019;23:1158–65. doi:10.1007/s10461-018-2287-y
      OpenUrl
    14. ↵
      1. Liu Y,
      2. Vermund SH,
      3. Ruan Y, et al
      . Peer counselling versus standard-of-care on reducing high-risk behaviours among newly diagnosed HIV-positive men who have sex with men in Beijing, China: a randomized intervention study. J Int AIDS Soc 2018;21:e25079. doi:10.1002/jia2.25079
    15. ↵
      1. Webel AR
      . Testing a peer-based symptom management intervention for women living with HIV/AIDS. AIDS Care 2010;22:1029–40. doi:10.1080/09540120903214389
      OpenUrlCrossRefPubMed
    16. ↵
      1. Mead S,
      2. MacNeil C
      . Peer support: what makes it unique? International Journal of Psychosocial Rehabilitation 2006;10:29–37.
      OpenUrl
    17. ↵
      1. Bagnall A-M,
      2. South J,
      3. Hulme C, et al
      . A systematic review of the effectiveness and cost-effectiveness of peer education and peer support in prisons. BMC Public Health 2015;15:290. doi:10.1186/s12889-015-1584-x
    18. ↵
      1. Chola L,
      2. Fadnes LT,
      3. Engebretsen IMS, et al
      . Cost-Effectiveness of peer counselling for the promotion of exclusive breastfeeding in Uganda. PLoS One 2015;10:e0142718. doi:10.1371/journal.pone.0142718
    19. ↵
      1. British HIV Association (BHIVA), National HIV Nurses Association (NHIVNA), Children’s HIV Association (CHIVA)
      . National standards for peer support in HIV. 2017. Available: http://hivpeersupport.com/wp-content/uploads/2017/08/national_standards_final_web.pdf
    20. ↵
      1. NAPWHA
      . Australian HIV peer support standards. 2020. Available: https://napwha.org.au/resource/australian-hiv-peer-support-standards/
    21. ↵
      1. CATIE
      . Practice guidelines in peer health navigation for people living with HIV. CATIE - canada’s source for HIV and hepatitis C information. 2018. Available: https://www.catie.ca/practice-guidelines-in-peer-health-navigation-for-people-living-with-hiv [Accessed 4 Jun 2022].
    22. ↵
      1. UNAIDS
      . Confronting inequalities: lessons for pandemic responses from 40 years of AIDS. n.d. Available: https://www.unaids.org/en/resources/presscentre/pressreleaseandstatementarchive/2021/july/20210714 _global-aids-update
    23. ↵
      1. Brashers DE,
      2. Basinger ED,
      3. Rintamaki LS, et al
      . Taking control: the efficacy and durability of a peer-led uncertainty management intervention for people recently diagnosed with HIV. Health Commun 2017;32:11–21. doi:10.1080/10410236.2015.1089469
      OpenUrl
    24. ↵
      1. Reback CJ,
      2. Kisler KA,
      3. Fletcher JB
      . A novel adaptation of peer health navigation and contingency management for advancement along the HIV care continuum among transgender women of color. AIDS Behav 2021;25:40–51. doi:10.1007/s10461-019-02554-0
      OpenUrlPubMed
    25. ↵
      1. Graham SM,
      2. Micheni M,
      3. Chirro O, et al
      . A randomized controlled trial of the shikamana intervention to promote antiretroviral therapy adherence among gay, bisexual, and other men who have sex with men in Kenya: feasibility, acceptability, safety and initial effect size. AIDS Behav 2020;24:2206–19. doi:10.1007/s10461-020-02786-5
      OpenUrlPubMed
    26. ↵
      1. He J,
      2. Wang Y,
      3. Du Z, et al
      . Peer education for HIV prevention among high-risk groups: a systematic review and meta-analysis. BMC Infect Dis 2020;20:338. doi:10.1186/s12879-020-05003-9
    27. ↵
      1. Denison JA,
      2. Burke VM,
      3. Miti S, et al
      . Project Yes! youth engaging for success: a randomized controlled trial assessing the impact of a clinic-based peer mentoring program on viral suppression, adherence and internalized stigma among HIV-positive youth (15-24 years) in ndola, Zambia. PLoS One 2020;15:e0230703. doi:10.1371/journal.pone.0230703
    28. ↵
      1. Mavhu W,
      2. Willis N,
      3. Mufuka J, et al
      . Effect of a differentiated service delivery model on virological failure in adolescents with HIV in zimbabwe (zvandiri): a cluster-randomised controlled trial. Lancet Glob Health 2020;8:e264–75. doi:10.1016/S2214-109X(19)30526-1
      OpenUrl
    29. ↵
      1. Orne-Gliemann J,
      2. Font H,
      3. Maphosa T, et al
      . Patterns of attendance at mother support groups in Zimbabwe. The EPAZ trial (2014-2016). J Acquir Immune Defic Syndr 2017;75 Suppl 2:S216–23. doi:10.1097/QAI.0000000000001348
      OpenUrl
    30. ↵
      1. Mudiope P,
      2. Musingye E,
      3. Makumbi CO, et al
      . Greater involvement of HIV-infected peer-mothers in provision of reproductive health services as “family planning champions” increases referrals and uptake of family planning among HIV-infected mothers. BMC Health Serv Res 2017;17:444. doi:10.1186/s12913-017-2386-x
    31. ↵
      1. Woznica DM,
      2. Fernando NB,
      3. Bonomo EJ, et al
      . Interventions to improve HIV care continuum outcomes among individuals released from prison or jail: systematic literature review. J Acquir Immune Defic Syndr 2021;86:271–85. doi:10.1097/QAI.0000000000002523
      OpenUrl
    32. ↵
      1. Berg RC,
      2. Page S,
      3. Øgård-Repål A
      . The effectiveness of peer-support for people living with HIV: a systematic review and meta-analysis. PLoS One 2021;16:e0252623. doi:10.1371/journal.pone.0252623
    33. ↵
      1. Boucher LM,
      2. Liddy C,
      3. Mihan A, et al
      . Peer-led self-management interventions and adherence to antiretroviral therapy among people living with HIV: a systematic review. AIDS Behav 2020;24:998–1022. doi:10.1007/s10461-019-02690-7
      OpenUrl
    34. ↵
      1. Pawson R,
      2. Greenhalgh T,
      3. Harvey G, et al
      . Realist synthesis: an introduction. Manchester: University of Manchester, 2004.
    35. ↵
      1. Wong G,
      2. Greenhalgh T,
      3. Westhorp G, et al
      . RAMESES publication standards: realist syntheses. J Adv Nurs 2013;69:1005–22. doi:10.1111/jan.12095
      OpenUrlCrossRefPubMed
    36. ↵
      1. National Institute for Health Research (NIHR)
      . PROSPERO international prospective register of systematic reviews. 2022. Available: https://www.crd.york.ac.uk/prospero/
    37. ↵
      1. Pawson R,
      2. Greenhalgh T,
      3. Harvey G, et al
      . Realist review -- a new method of systematic review designed for complex policy interventions. J Health Serv Res Policy 2005;10 Suppl 1:21–34. doi:10.1258/1355819054308530
      OpenUrlPubMed
    38. ↵
      CATIE - canada’s source for HIV and hepatitis C information. Available: https://www.catie.ca/catie-canadas-source-for-hiv-and-hepatitis-c-information [Accessed 2 Jun 2022].
    39. ↵
      1. BHIVA
      . Homepage. Available: https://www.bhiva.org/index.php [Accessed 2 Jun 2022].
    40. ↵
      1. NAPWHA
      . Homepage. Available: https://napwha.org.au/ [Accessed 2 Jun 2022].
    41. ↵
      1. NHIVNA
      . Homepage. Available: https://www.nhivna.org/index.php [Accessed 2 Jun 2022].
    42. ↵
      1. UNAIDS
      . Homepage. Available: https://www.unaids.org/en [Accessed 2 Jun 2022].
    43. ↵
      1. Rycroft-Malone J,
      2. McCormack B,
      3. Hutchinson AM, et al
      . Realist synthesis: illustrating the method for implementation research. Implement Sci 2012;7:33. doi:10.1186/1748-5908-7-33
      OpenUrlCrossRefPubMed
    44. ↵
      1. CATIE
      . Peer navigation services. CATIE - canada’s source for HIV and hepatitis C information. 2013. Available: https://www.catie.ca/programming-connection/peer-navigation-services [Accessed 4 Jun 2022].
    45. ↵
      1. CATIE
      . Getting started: A guide to develop and deliver peer support services. CATIE - canada’s source for HIV and hepatitis C information. Available: https://www.catie.ca/resource/getting-started-a-guide-to-develop-and-deliver-peer-support-services [Accessed 4 Jun 2022].
    46. ↵
      1. CATIE
      . Training peer mentors: facilitation guide. CATIE - canada’s source for HIV and hepatitis C information. 2018. Available: https://www.catie.ca/resource/training-peer-mentors-facilitation-guide [Accessed 4 Jun 2022].
    47. ↵
      1. CATIE
      . Becoming a peer mentor: participant training guide. CATIE - canada’s source for HIV and hepatitis C information. 2018. Available: https://www.catie.ca/resource/becoming-a-peer-mentor-participant-training-guide [Accessed 4 Jun 2022].
    48. ↵
      1. Dutcher MV,
      2. Phicil SN,
      3. Goldenkranz SB, et al
      . “ positive examples ”: a bottom-up approach to identifying best practices in HIV care and treatment based on the experiences of peer educators. AIDS Patient Care STDS 2011;25:403–11. doi:10.1089/apc.2010.0388
      OpenUrlCrossRefPubMed
    49. ↵
      1. Houston E,
      2. Osborn A,
      3. Lyons T, et al
      . Exploring perceived social support from peer facilitators in an HIV treatment adherence intervention for african american patients: a content analysis of participant perspectives. J Community Appl Soc Psychol 2015;25:487–501. doi:10.1002/casp.2228
      OpenUrl
    50. ↵
      1. Peterson JL,
      2. Rintamaki LS,
      3. Brashers DE, et al
      . The forms and functions of peer social support for people living with HIV. J Assoc Nurses AIDS Care 2012;23:294–305. doi:10.1016/j.jana.2011.08.014
      OpenUrlCrossRefPubMed
    51. ↵
      1. Sun W,
      2. Lu H,
      3. Bao M, et al
      . Experience of treatment naïve HIV patients receiving peer support: a qualitative study. Chinese Journal of AIDS & STD 2020;26:496–9.
      OpenUrl
    52. ↵
      1. Khalpey Z,
      2. Fitzgerald L,
      3. Howard C, et al
      . Peer navigators’ role in supporting people living with human immunodeficiency virus in Australia: qualitative exploration of general practitioners’ perspectives. Health Soc Care Community 2022;30:1353–62. doi:10.1111/hsc.13465
      OpenUrl
    53. ↵
      1. Øgård-Repål A,
      2. Berg RC,
      3. Skogen V, et al
      . Peer support in an outpatient clinic for people living with human immunodeficiency virus: a qualitative study of service users’ experiences. BMC Health Serv Res 2022;22:549. doi:10.1186/s12913-022-07958-8
    54. ↵
      1. Harris GE,
      2. Larsen D
      . Hiv peer counseling and the development of hope: perspectives from peer counselors and peer counseling recipients. AIDS Patient Care STDS 2007;21:843–60. doi:10.1089/apc.2006.0207
      OpenUrlCrossRefPubMedWeb of Science
    55. ↵
      1. Mantell JE,
      2. Masvawure TB,
      3. Mapingure M, et al
      . Engaging men in HIV programmes: a qualitative study of male engagement in community-based antiretroviral refill groups in Zimbabwe. J Int AIDS Soc 2019;22:e25403. doi:10.1002/jia2.25403
    56. ↵
      1. Arem H,
      2. Nakyanjo N,
      3. Kagaayi J, et al
      . Peer health workers and AIDS care in Rakai, Uganda: a mixed methods operations research evaluation of a cluster-randomized trial. AIDS Patient Care STDS 2011;25:719–24. doi:10.1089/apc.2010.0349
      OpenUrlCrossRefPubMedWeb of Science
    57. ↵
      1. Chang LW,
      2. Kagaayi J,
      3. Nakigozi G, et al
      . Effect of peer health workers on AIDS care in Rakai, Uganda: a cluster-randomized trial. PLoS One 2010;5:e10923. doi:10.1371/journal.pone.0010923
    58. ↵
      1. Enriquez M,
      2. Cheng A-L,
      3. McKinsey D, et al
      . Peers keep it real: re-engaging adults in HIV care. J Int Assoc Provid AIDS Care 2019;18:2325958219838858. doi:10.1177/2325958219838858
    59. ↵
      1. Parker R,
      2. Jelsma J,
      3. Stein DJ
      . Managing pain in women living with HIV/AIDS: a randomized controlled trial testing the effect of a six-week peer-led exercise and education intervention. J Nerv Ment Dis 2016;204:665–72. doi:10.1097/NMD.0000000000000506
      OpenUrlPubMed
    60. ↵
      1. Van Tam V,
      2. Larsson M,
      3. Pharris A, et al
      . Peer support and improved quality of life among persons living with HIV on antiretroviral treatment: a randomised controlled trial from north-eastern Vietnam. Health Qual Life Outcomes 2012;10:53. doi:10.1186/1477-7525-10-53
    61. ↵
      1. Cabral HJ,
      2. Davis-Plourde K,
      3. Sarango M, et al
      . Peer support and the HIV continuum of care: results from a multi-site randomized clinical trial in three urban clinics in the United States. AIDS Behav 2018;22:2627–39. doi:10.1007/s10461-017-1999-8
      OpenUrl
    62. ↵
      1. Chang LW,
      2. Nakigozi G,
      3. Billioux VG, et al
      . Effectiveness of peer support on care engagement and preventive care intervention utilization among pre-antiretroviral therapy, HIV-infected adults in Rakai, Uganda: a randomized trial. AIDS Behav 2015;19:1742–51. doi:10.1007/s10461-015-1159-y
      OpenUrlPubMed
    63. ↵
      1. Enriquez M,
      2. Cheng A-L,
      3. Banderas J, et al
      . A peer-led HIV medication adherence intervention targeting adults linked to medical care but without a suppressed viral load. J Int Assoc Provid AIDS Care 2015;14:441–8. doi:10.1177/2325957414558301
      OpenUrlCrossRefPubMed
    64. ↵
      1. Pearson CR,
      2. Micek MA,
      3. Simoni JM, et al
      . Randomized control trial of peer-delivered, modified directly observed therapy for HAART in Mozambique. J Acquir Immune Defic Syndr 2007;46:238–44. doi:10.1097/QAI.0b013e318153f7ba
      OpenUrlCrossRefPubMedWeb of Science
    65. ↵
      1. Simoni JM,
      2. Huh D,
      3. Frick PA, et al
      . Peer support and pager messaging to promote antiretroviral modifying therapy in Seattle: a randomized controlled trial. J Acquir Immune Defic Syndr 2009;52:465–73. doi:10.1097/qai.0b013e3181b9300c
      OpenUrlCrossRefPubMed
    66. ↵
      1. Aung S,
      2. Hardy N,
      3. Chrysanthopoulou S, et al
      . Evaluation of peer-to-peer HIV counseling in Myanmar: a measure of knowledge, adherence, and barriers. AIDS Care 2022;34:762–70. doi:10.1080/09540121.2021.1902929
      OpenUrl
    67. ↵
      1. Kemp C,
      2. Gerth-Guyette E,
      3. Dube L, et al
      . Mixed-Methods evaluation of a novel, structured, community-based support and education intervention for individuals with HIV/AIDS in KwaZulu-Natal, South Africa. AIDS Behav 2016;20:1937–50. doi:10.1007/s10461-016-1386-x
      OpenUrl
    68. ↵
      1. Boyd MR,
      2. Moneyham L,
      3. Murdaugh C, et al
      . A peer-based substance abuse intervention for HIV+ rural women: a pilot study. Arch Psychiatr Nurs 2005;19:10–7. doi:10.1016/j.apnu.2004.11.002
      OpenUrlCrossRefPubMed
    69. ↵
      1. Mackenzie S,
      2. Pearson C,
      3. Frye V, et al
      . Agents of change: peer mentorship as HIV prevention among HIV-positive injection drug users. Subst Use Misuse 2012;47:522–34. doi:10.3109/10826084.2012.644122
      OpenUrlPubMedWeb of Science
    70. ↵
      1. Pearson CR,
      2. Micek M,
      3. Simoni JM, et al
      . Modified directly observed therapy to facilitate highly active antiretroviral therapy adherence in beira, mozambique. development and implementation. J Acquir Immune Defic Syndr 2006;43 Suppl 1:S134–41. doi:10.1097/01.qai.0000248339.82567.17
      OpenUrl
    71. ↵
      1. Tobias CR,
      2. Rajabiun S,
      3. Franks J, et al
      . Peer knowledge and roles in supporting access to care and treatment. J Community Health 2010;35:609–17. doi:10.1007/s10900-010-9250-9
      OpenUrlPubMed
    72. ↵
      1. Hilfinger Messias DK,
      2. Moneyham L,
      3. Vyavaharkar M, et al
      . Embodied work: insider perspectives on the work of HIV/AIDS peer counselors. Health Care Women Int 2009;30:572–94. doi:10.1080/07399330902928766
      OpenUrlPubMedWeb of Science
    73. ↵
      1. Messias DKH,
      2. Moneyham L,
      3. Murdaugh C, et al
      . Hiv/Aids peer counselors’ perspectives on intervention delivery formats. Clin Nurs Res 2006;15:177–96. doi:10.1177/1054773806288568
      OpenUrlCrossRefPubMed
    74. ↵
      1. Sun W,
      2. Bao M,
      3. Lu H, et al
      . Peer supporter’ experience for people with AIDS: a qualitative study. Journal of Modern Nusing 2019;25:2788–92.
      OpenUrl
    75. ↵
      1. Yard SS,
      2. Huh D,
      3. King KM, et al
      . Patient-Level moderators of the efficacy of peer support and pager reminder interventions to promote antiretroviral adherence. AIDS Behav 2011;15:1596–604. doi:10.1007/s10461-011-0001-4
      OpenUrlPubMed
    76. ↵
      1. Gusdal AK,
      2. Obua C,
      3. Andualem T, et al
      . Peer counselors’ role in supporting patients’ adherence to ART in ethiopia and uganda. AIDS Care 2011;23:657–62. doi:10.1080/09540121.2010.532531
      OpenUrlCrossRefPubMed
    77. ↵
      1. Karver TS,
      2. Barrington C,
      3. Donastorg Y, et al
      . Exploring peer navigation and support in the quality of HIV care experiences of female sex workers in the dominican republic. BMC Health Serv Res 2022;22:56. doi:10.1186/s12913-021-07439-4
    78. ↵
      1. Monroe A,
      2. Nakigozi G,
      3. Ddaaki W, et al
      . Qualitative insights into implementation, processes, and outcomes of a randomized trial on peer support and HIV care engagement in rakai, uganda. BMC Infect Dis 2017;17:54. doi:10.1186/s12879-016-2156-0
      OpenUrlPubMed
    79. ↵
      1. Marino P,
      2. Simoni JM,
      3. Silverstein LB
      . Peer support to promote medication adherence among people living with HIV/AIDS: the benefits to peers. Soc Work Health Care 2007;45:67–80. doi:10.1300/J010v45n01_05
      OpenUrlCrossRefPubMedWeb of Science
    80. ↵
      1. de Souza R
      . A qualitative study of roles performed by peer workers in the context of HIV in india. J Assoc Nurses AIDS Care 2014;25:176–87. doi:10.1016/j.jana.2013.01.004
      OpenUrl
    81. ↵
      1. Li D,
      2. Xu X,
      3. Li M
      . Qualitative research on the work experience of AIDS peer educators. Chinese Journal of AIDS & STD 2017;23:65–8.
      OpenUrl
    82. ↵
      1. Lee HJ,
      2. Moneyham L,
      3. Kang HS, et al
      . Peer supporter experiences of home visits for people with HIV infection. HIV AIDS (Auckl) 2015;7:233–9. doi:10.2147/HIV.S89436
      OpenUrl
    83. ↵
      1. Hallum-Montes R,
      2. Morgan S,
      3. Rovito HM, et al
      . Linking Peers, patients, and providers: a qualitative study of a peer integration program for hard-to-reach patients living with HIV/AIDS. AIDS Care 2013;25:968–72. doi:10.1080/09540121.2012.748869
      OpenUrlCrossRefPubMed
    84. ↵
      1. Greene S,
      2. Ahluwalia A,
      3. Watson J, et al
      . Between skepticism and empowerment: the experiences of peer research assistants in HIV/AIDS, housing and homelessness community‐based research. International Journal of Social Research Methodology 2009;12:361–73. doi:10.1080/13645570802553780
      OpenUrl
    85. ↵
      1. Dickinson D,
      2. Kgatea KD
      . Workplace peer educators and stress. Afr J AIDS Res 2008;7:293–303. doi:10.2989/AJAR.2008.7.3.6.653
      OpenUrl
    86. ↵
      1. Steward WT,
      2. Sumitani J,
      3. Moran ME, et al
      . Engaging HIV-positive clients in care: acceptability and mechanisms of action of a peer navigation program in south africa. AIDS Care 2018;30:330–7. doi:10.1080/09540121.2017.1363362
      OpenUrlPubMed
    87. ↵
      1. Jackson K,
      2. Wadley AL,
      3. Parker R
      . Managing pain in HIV/AIDS: a therapeutic relationship is as effective as an exercise and education intervention for rural amaxhosa women in south africa. BMC Public Health 2021;21:302. doi:10.1186/s12889-021-10309-7
    88. ↵
      1. Masquillier C,
      2. Wouters E,
      3. Mortelmans D, et al
      . Families as catalysts for peer adherence support in enhancing hope for people living with HIV/AIDS in south africa. J Int AIDS Soc 2014;17:18802. doi:18802
    89. ↵
      1. Simoni JM,
      2. Pantalone DW,
      3. Plummer MD, et al
      . A randomized controlled trial of A peer support intervention targeting antiretroviral medication adherence and depressive symptomatology in HIV-positive men and women. Health Psychol 2007;26:488–95. doi:10.1037/0278-6133.26.4.488
      OpenUrlCrossRefPubMedWeb of Science
    90. ↵
      1. Giordano TP,
      2. Cully J,
      3. Amico KR, et al
      . A randomized trial to test A peer mentor intervention to improve outcomes in persons hospitalized with HIV infection. Clin Infect Dis 2016;63:678–86. doi:10.1093/cid/ciw322
      OpenUrlCrossRefPubMed
    91. ↵
      1. Ruiz I,
      2. Olry A,
      3. López MA, et al
      . Prospective, randomized, two-arm controlled study to evaluate two interventions to improve adherence to antiretroviral therapy in spain. Enferm Infecc Microbiol Clin 2010;28:409–15. doi:10.1016/j.eimc.2009.03.018
      OpenUrlPubMed
    92. ↵
      1. Senn TE,
      2. Braksmajer A,
      3. Coury-Doniger P, et al
      . Development and preliminary pilot testing of a peer support text messaging intervention for HIV-infected black men who have sex with men. J Acquir Immune Defic Syndr 2017;74 Suppl 2:S121–7. doi:10.1097/QAI.0000000000001241
      OpenUrl

    Supplementary materials

    • Supplementary Data

      This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.

    Footnotes

    • SH and YZ are joint first authors.

    • Handling editor Stephanie M Topp

    • SH and YZ contributed equally.

    • Contributors SH: Conceptualisation, Writing—original draft, Funding acquisition. YZ: Conceptualisation, Writing—original draft. XY: Conceptualisation, Writing—original draft. XC: Methodology, Validation. JG: Methodology, Validation. LZ: Writing—review and editing, Supervision. YS: Writing—review and editing. JM: Writing—review and editing. KL: Methodology, Validation. ZW: Supervision, Writing—review and editing, Project administration, Guarantor.

    • Funding This study was funded by the National Natural Science Foundation of China (72204006), the China Postdoctoral Science Foundation (2022M710258), the Ministry of Education of Humanities and Social Science Project (22YJCZH044) and the Peking University Evidence-Based Nursing Special Research Foundation (XZJJ-2022-10).

    • Competing interests None declared.

    • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

    • Provenance and peer review Not commissioned; externally peer reviewed.

    • Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.